107 COLUMBUS AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
n, ,l ';►� Board ot'Building Regulations and Standards CITY
Massachusetts State BuildingCode, 780 C'MR, T°edition OF SALEM
1. r Revised Junuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Arco-Family Dwelling
This Section For Official Use Only
y, y Building Permit Numbe . �/ Date Applied:
Signature: //b
Building Commissioner/Ins or of Buildings Iktte
SECTION I: SITE INFORMATION
1.1 Properly Address: 1.2 Assessors Map di Parcel Number
I.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Z n Information: 1.4 Property Dimensions:
Zoning Dlstnct Proposed Use La Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage/Disposal System:
Public Zone: _ Oubide Flood�7 pa ill 0n site disposal system ❑
li)' Private❑ Check if es Municipal
J SECTION 2: PROPERTY OWNERSHIP'
2�0 A 24 fce Ro �
a.
Nome ri ) Address for Service:
r 970 4Dw
Signature Telephone
SECTION): DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.O 1 Number of Units_ Other ❑ Speciry:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials y
1. Building IS ��D�," 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
3�D' ❑Total Project Costs(Item 6)x multiplier x
5. Plumbing Is 41ca 0'V 2. Other Fees: S
4. Mechanical (HVAC) s .4&G . Ob List:
5. Mechanical (Fire
Suppression) s Total All Fees:s
Check No. Check Amount: Cash Amount:
b. Total Project Coat: s f� �/ /J ❑Paid in Full ❑Outstanding Balance Due:/' /
y
J
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number hspimtion Date
Name of(.'St..lhdder 1.ist CSL'type life below)
t lk-scrieRion
Address U Unrestricted(up to JS,000 Cu.Ft.
R I Restricted IR2 Famil DJ elfin
Signature M Masonry Only
RC Residential Roofing Covering
I'dephone WS Residential Window and Sidin
SF Residential Solid Fuel Rumin A liance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
f 11C Company Na or HIC Registrant Name Registration Number
Nam
Address Etpimlion Date
Signature 'telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152./ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........0 No........... O
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
*A L Lr- /Z, �/P , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work.�authorized by this building permit application.
Si ure of owner Date
n SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
\ // 1 /yJD jf =j. J�L ,/�✓o y'/A ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf. /r,601� )LicG'i��j�j�
PrJ/ N e (I ` �,—/110.�C0/d
Signature ot'Owner or Aut orfzcd Agent Date
70wner
the pains and penalties ofperjury)
NOTES:
er who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
tered in the Home Improvement Contractor(HIC)Program), will M have access to the arbitration
or guaranty fund under M.G.L.c. 1J2A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 IO.RS, respectively.
2. bstantial work is planned,provide the information below:
ea(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S.ULE.Ni
PUBLIC PROPERTY
DEPARTtitENT
K1f0lfliY tv".vv
MAVQG - 130 WARWAGI M SMW• &UA MAMACMSans 019'0
tIM s-s.?s-s»s • F.%x 97&.?4&964
HOMEOWNER LICENSE EXE.MMON
Pigs" Mist
Date g /G ,?v/O
Jab Location US'
Home Owner Address ,— S%
Home Owner Telepbone - , �a - 4/,?4z
Present Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOIMOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwellin& attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
.APPROVAL OF BUILDING INSPECTOR (it�ti
See other side for state code
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CITY OF SALEM
r A PUBLIC PROPRERTY
DEPAKT'.1IENT
t1: U-.�,rnv,,oNS imr.r r • Sli i Nt. \In,;v ... i . .i �
Construction Debris Disposal Affidavit
(raluired lix all demolition and renovation work)
In accordance l%ith the sixth edition of the State Building Code, 780 Cb1R section 1 1 1.5
Debris, and the provisions of%1GL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
Iname of muter)
The debris will be disposed of in : ,(l-a
(name ut facility)
(address of lacilily) n
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